<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004252
Report Date: 12/16/2024
Date Signed: 12/16/2024 01:31:17 PM

Document Has Been Signed on 12/16/2024 01:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AMAZING GRACE & CAREFACILITY NUMBER:
306004252
ADMINISTRATOR/
DIRECTOR:		ELENA BORFACILITY TYPE:
740
ADDRESS:900 N. CARHART AVENUETELEPHONE:
(714) 870-0309
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 5DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:22 AM
MET WITH:Elena Bor - AdminstratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Administrator Elena Bor and explained the purpose for today’s visit. The facility is licensed to serve 6 Non-Ambulatory Residents, with a Hospice Waiver for 6. The facility currently has 6 Residents, 5 of which receive Hospice Services.

The facility is a two-story home located in Fullerton, Ca (only the first floor is licensed to provide care and supervision). A tour of the facility includes: Living room, 2 dining areas/room, 5 Resident Bedrooms (1 is a shared room), 4 full baths located in 4 of the resident bedrooms, 1 full bathroom, front yard, back yard, detached garage, and a pool (which is fully fenced). 2nd floor is private residence for Administrator.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following:


Infection Control: Facility has sufficient PPE supplies and Infection Control Plan maintained at the facility.
Operational Requirements: The facility has an approved fire clearance and maintain the required liability insurance. During resident file review it was observed that Resident #1 is bedridden, per their physician report dated 8/21/24, facility has fire clearance for Non-Ambulatory Residents Only, citation will be issued along with civil penalties as facility is operating outside of what they are approved for.
Staffing: There appears to be sufficient staffing at all times in the facility.
Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in dementia, hospice care, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 4 staff files with no issues observed. Administrator Elena Bor certificate expires 6/17/24.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
(Continued on LIC809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 12/16/2024 01:31 PM - It Cannot Be Edited


Created By: Tena Herrera On 12/16/2024 at 12:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AMAZING GRACE & CARE
FACILITY NUMBER: 306004252

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview with Administrator and Resident #1 record review, the licensee did not comply with the section cited above as per the physician report dated 8/21/24 Resident #1 is documented as Bedridden, upon arrival LPA asked Administrator how many residents facility has and Administrator confirmed 6 with 1 bedridden, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
1
2
3
4
Administrator/Licensee to contact their fire department and advise them that the facility has 1 bedridden resident and are operating outside of what their fire clearance is approved for, documentation of report and contact name/number is to be emailed to LPA by end of business day 12/17/24. Additionally Administrator/Licensee is to develop a plan to be in compliance the two options will be to submit an updated LIC200 and Facility sketch indicating update to bedridden (must email to LPA by end of business day 12/17/24), or find alternative for Resident #1's safety and Facility Compliance. (again information must be submitted to LPA via email by end of business day 12/17/24). tena.herrera@dss.ca.gov
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/16/2024 01:31 PM - It Cannot Be Edited


Created By: Tena Herrera On 12/16/2024 at 12:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AMAZING GRACE & CARE
FACILITY NUMBER: 306004252

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as LPA tested the water temperature in Room 1 and Single Full Bath (Bath 1) and water temperature measured between 80-86 degrees F, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
1
2
3
4
Administrator/Licensee to create a water temperature log for the next 3 consecutive days, measuring water temperature 3 times a day (morning, afternoon, evening) and document date/time/reading on log, all readings must be within the required temperature of 105-120 degrees F. Completed water temperature log must be submitted to LPA by POC due date of 12/20/24. tena.herrera@dss.ca.gov
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the last documented emergency drill was dated 6/26/24, when LPA asked Administrator if this was the last drill Administrator stated that fire department came in November, LPA asked for doumentation of visit with what was inspected and proof of a drill, however, Administrator was not able to provide that to LPA during visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
1
2
3
4
Licensee/Administrator to schedule and conducted the required emergency drill and submit a copy of drill (that shows date/time/what drill was conducted/participants) and email to LPA by POC due date. (tena.herrera@dss.ca.gov)
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AMAZING GRACE & CARE
FACILITY NUMBER: 306004252
VISIT DATE: 12/16/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. Facility has a pool in the back yard that is completely fenced and locked. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and, 1/2 of the facility measured below the required range of 105-120 degrees F, measuring at 80-86 degrees F, citation will be issued. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Last fire/disaster/earthquake drill was conducted on 6/26/24 citation will be issued.
Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 4 Resident Files with no issues observed.
Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman.
Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents.
Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. LPA reviewed residents’ medications and there were no issues observed.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: There is 1 bedridden at this facility. Facility has 5 residents using hospice services and maintain the required hospice care plan.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during the visit will be documented in the LIC809D. Civil Penalties were issued during visit.

Exit interview held and a copy of the report, LIC421IM (Civil Penalty Assessment), and appeal rights were provided to Administrator Elena Bor.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4